TRIBAL LAW AND ORDER ACT SAMHSA’S WORK TO IMPROVE BEHAVIORAL HEALTH

IN INDIAN COUNTRY Pamela S. Hyde, J.D.

SAMHSA Administrator

DEPARTMENT OF HEALTH AND HUMAN SERVICES2011 Region I – New England Tribal Consultation

Boston, MA • March 31, 2011

A TIME OF CHANGE

Economic challenges like never before

Promising partnerships between Tribes and Federal Government

Self-determination approaches

New prevention and treatment opportunities

Tribal Law and Order Act (TLOA)

Affordable Care Act/Health Reform (including Indian Health Care Improvement Act)

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EASY TO LOSE FOCUS ON HOW TO BEST MEET NEEDS OF COMMUNITIES

Rural Tribal Communities vs. Urban

Traditional Approaches to Healing vs. Modern

Story-telling vs. Science

Treatment: Spiritually, Traditionally, Ceremonially or Scientifically?

Modern AI/AN Communities: • Multitribal

• Multiethnic

• Multiracial

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SAMHSA LEADING CHANGE

Mission: To reduce the impact of substance abuse and mental illness on America’s communities

Roles: • Leadership and Voice• Funding - Service Capacity Development• Information/Communications• Regulation and Standard setting• Practice Improvement

Leading Change – 8 Strategic Initiatives

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HHS STRATEGIC PLANS SAMHSA STRATEGIC INITIATIVES

AIM: Improving the Nation’s Behavioral Health1 Prevention2 Trauma and Justice3 Military Families4 Recovery Support

AIM: Transforming Health Care in America5 Health Reform6 Health Information Technology

AIM: Achieving Excellence in Operations7 Data, Outcomes & Quality8 Public Awareness & Support

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SAMHSA STRATEGIC INITIATIVE PREVENTION

Challenges in AI/AN Communities:Higher adolescent death ratesHigher youth suicide ratesHigher past month binge alcohol useHigher past month illicit drug useHigher sexual assault rates against femalesHigher homicide rates against women Higher rates of intimate partner violence against womenHigher rates of incarceration and arrestHigher rates of historical trauma

Lower M/SUD treatment rates in non-HIS/specialty treatment settings

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SAMHSA STRATEGIC INITIATIVE PREVENTION

Prevent Substance Abuse and Mental Illness (Including Tobacco) and Build Emotional Health

Prevention Prepared Communities (PPCs)

Suicide

Underage Drinking/Alcohol Polices

Prescription Drug Abuse

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Percent of persons 12 or older who met criteria for substance abuse or dependence by race/ethnicity: 2009

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

*

*Low precision; no estimate reported Source: 2009 NSDUH

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Perc

ent w

ith s

ubst

ance

abu

se o

r dep

ende

nce

Percent of persons 18 or older who met criteria for any mental illness by race/ethnicity: 2009

0%

5%

10%

15%

20%

25%

30%

35%

Perc

ent w

ith a

ny m

enta

l illn

ess

in p

ast y

ear

Source: 2009 NSDUH

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PROPOSED FOR FY 2012: BEHAVIORAL HEALTH – TRIBAL PREVENTION GRANT (BH-TPG)

Proposed new discretionary grant program in the President’s 2012 Budget ($50 million)• Authorized from the Prevention and Public Health Fund and appropriated by

the Affordable Care Act (ACA)

FOCUS ON PREVENTION OF SUBSTANCE ABUSE AND SUICIDESAMHSA will coordinate with IHS to implement community-based

prevention strategies that complement the clinical services provided by IHS-funded providers

Non-competitive application process; every 3 yrs & annual reporting

All federally-recognized tribes eligible to receive fundingFormula to be determined after consultation with Tribal leaders

• Likely a base amount with additional $ depending on populationand need

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BH-TPG FORMULA CONSIDERATIONS

• Scenario #1 w/base amount of $50,000• At 100 percent request = total base allocation of $28,250,000• Additional $21,750,000 to be distributed (Formula TBD)

• Scenario # 2 w/base amount of $50,000• At 75 percent request = total base allocation of $21,150,000• Additional $28,850,000 to be distributed (Formula TBD)

• Scenario #3 w/base amount of $35,000• At 100 percent request = total base allocation of $19,775,000• Additional $30,225,000 to be distributed (Formula TBD)

• Scenario #4 w/base amount of $35,000• At 75 percent request = total base allocation of $14,805,000• Additional $35,195,000 to be distributed (Formula TBD)

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If less than 100 percent apply do we increase base so base and additional amounts are relatively equal?

What criteria should be used for calculating the formula for the non-base portion of the funding?

If SAMHSA does not receive full amount requested, how should funding be distributed?

BH-TPG FORMULA CONSIDERATIONS13

JULY 29, 2010 TRIBAL LAW AND ORDER ACT (TLOA) SIGNED INTO LAW

The Act reauthorizes and amends the Indian Alcohol and Substance Abuse Prevention and Treatment Act (IASA) of 1986

• Title II - Tribal Law and Order

• Subtitle D - Tribal Justice Systems

• Section 241 - Specifically addresses SAMHSA’s responsibilities

TLOA requires the Federal Government to better coordinate efforts, resources, and services to address the unique challenges in Indian Country

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KEY TLOA FEDERAL PARTICIPANTS

• Office of the President (President)• Majority Leader of the Senate• Minority Leader of Senate• Speaker of the House of

Representatives• Minority Leader of the House of

Representatives• The Office of the Attorney General• The Secretary of the Interior• The Secretary of Health and Human

Services• Department of Education• Office of Justice Services• Department of Justice

• Federal Bureau of Investigation• Indian Law and Order Commission• Administrative Office of the U.S. Courts• Bureau of Indian Affairs• GAO (Comptroller general)• The Office of the U.S. Attorney• Bureau of Prisons (Director of BOP)• Bureau of Indian Education• Indian Law Enforcement Foundation• Indian Health Services• SAMHSA• Native American Issues Coordinator

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CURRENT PARTNERS SAMHSA COULD LEVERAGE FOR WORK ON TLOA

Within Department of Health and Human Services (HHS)• Administration for Children and Families (ACF)• Administration on Aging (AoA)• Centers for Disease Control and Prevention (CDC)• Food and Drug Administration (FDA)• Health Resources and Services Administration (HRSA)• Indian Health Service (IHS)• National Institutes of Health (NIH)

• NIAAA• NIDA• NIMH• Office of Minority Health

• Office of the Surgeon General (OSG)• Centers for Medicare and Medicaid Services (CMS)

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CURRENT PARTNERS SAMHSA COULD LEVERAGE FOR WORK ON TLOA

Other Federal partners outside of HHS• Department of Defense (DOD)• Department of Education (ED)• Department of Interior (DOI)

• Bureau of Indian Affairs (BIA)• Bureau of Indian Education (BIE)

• Department of Justice (DOJ)• Drug Enforcement Administration (DEA)• Office of Juvenile Justice and Delinquency Prevention (OJJDP)• Office of Justice Programs (OJP)

• Office of National Drug Control Policy (ONDCP)

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TLOA SECTION 241 DELIVERABLES FOR SAMHSA

SAMHSA lead coordinating role:• Create and staff A SAMHSA Office of Indian Alcohol and

Substance Abuse (OIASA) – in Center for SA Prevention (CSAP)• Memorandum of Agreement between Justice, Interior and HHS

Secure w/ partners an MOA among HHS, DOI, and DOJ (by end of July 2011)

SAMHSA, IHS, BIA/BIE, DOJ Office of Justice Programs and ED as partners

• Securing operating framework of TAPs Work w/ interested Tribes on a TAP for combating alcohol and

substance abuse (relevant for available Federal resources)• Establish Inventory/Resource Workgroup

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SAMHSA lead coordinating role: • Newsletter Workgroup (25 U.S.C. 2416)

• Education Services Workgroup with focus on prevention for at-risk youth (25 U.S.C. 2431a)

Work w/BIE to improve summer prevention opportunities for at-risk youth

SAMHSA to become an equal, participating member on Federal Tribal Coordinating Committee (25 U.S.C. 2412)• Develop process with partners to monitor efforts & outcomes

TLOA SECTION 241 DELIVERABLES FOR SAMHSA

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DOI/BIAEnsure BH is

Part of Strategic Conversations

DOI/BIEPrevention forAt-risk Youth

DOJ/OJP/OTJto Improve

IASA Services/Resources

EDPartner to ↑ PreventionInitiatives

IHSMaximize

BH Resources

OIASA

SAMHSA’S OIASA COORDINATING RESPONSIBILITIES

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Also Engage:

•WHITCU

•ONDCP

•HUD

•DOL

•DOE

SAMHSA LEADERSHIP FOR IASA COORDINATED EFFORTS

TAPCOORDINATION

RESOURCEINVENTORY

NEWSLETTEREDUCATIONALRESOURCES

MOA

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OIASA

MOA WORKGROUP

Oversee legal review of documentEstablish and manage overall coordination of comments

from the various federal agenciesCompile, consolidate, and shepherd clearance processSecure final Cabinet-level signaturesCoordinate publication of MOA in Federal Register as

required by law• TLOA requires DOI, DOJ and HHS secure the MOA no later than

July 29, 2011

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TAP WORKGROUP

Establish operating framework and provide guidelines for Tribes consistent with requirements of available Federal resources

Develop inventory of current proven strategies - practice based evidence models

Manage overall coordination of Tribal requests for assistance in development of tribal action plans

Coordinate assistance/support to Tribes as deemed feasible

Collaborate with Inventory Workgroup in developing an appropriate response back to Tribal entities seeking assistance

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INVENTORY/RESOURCE WORKGROUP

Establish an operating model gather, maintain, and update current Federal efforts/capacity toward:• T/A contracts and services• Grants• Contracts• Cooperative agreements

Manage overall coordination of these effortsCollaborate with TAP Workgroup in developing

appropriate response back to Tribal entities seeking assistance

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NEWSLETTER WORKGROUP

Establish operating protocol and procedures to publish an alcohol and substance abuse newsletter reporting on Indian projects and programs• With Secretary of Health and Human Services• With Secretary of Education

Publish once in each calendar quarterInclude reviews of programs determined by the Secretary

of the Interior to be exemplaryProvide sufficient information to enable interested persons

to obtain further information about such programs

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EDUCATIONAL SERVICES WORKGROUP

Establish an operating model gather, maintain, and update current Federal efforts/capacity with toward:• Federal programs providing education services or benefits to Indian children• Tribal, State, local, and private educational resources and programs

Accomplished by• Secretary of the Interior• Attorney General• Secretary of Health and Human Services• Secretary of Education (In Cooperation)

Results of reviews provided to each Tribe as soon as possible for consideration/use in development/modification of a TAP

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WORK COMPLETED PROGRESS MADE

Outreach• National Tribal Organizations: NIHB , NCAI, NCUIH, AAIP,

NNAAPC, NIEA• Presentations: ATNI, NIEA, National Symposium, NAICJA,

Intertribal Court of Southern California, IC Detention Summit, Tribal Justice Jail Administrators' Forum , Intertribal Court Tribal Justice Council

• Federal Partners Engaged: DOE , DOI, DOJ, OAG, HHS• IASA Interdepartmental Coordinating Committee (4 Depts/15

Components/43 Members) MOU Tribal Action Plan

Attended and participated in several consultations/listening sessions

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HEALTH REFORM

“But if we're going to bring real and lasting change for Native Americans, we need a comprehensive strategy, as I said before. Part of that strategy is health care. We know that as long as Native Americans die of illnesses like tuberculosis, alcoholism, diabetes, pneumonia, and influenza at far higher rates than the rest of the population, then we're going to have to do more to address disparities in health care delivery.”

President Obama

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~25 percent American Indians/Alaska Natives live at poverty level

2006: 36 percent of American Indians/Alaska Natives had private health insurance coverage, and 24 percent relied on Medicaid coverage

2007: 33 percent had no health insurance coverage

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HEALTH REFORM CHALLENGES

HEALTH REFORM IMPACT OF AFFORDABLE CARE ACT

More people will have insurance coverage

• ↑Demand for qualified and well-trained BH professionals

Medicaid will play a bigger role in M/SUDs

Focus on primary care & coordination with specialty care

Major emphasis on home & community-based services; less reliance on institutional care

Theme: preventing diseases & promoting wellness

Focus on quality rather than quantity of care

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SAMHSA STRATEGIC INITIATIVEHEALTH REFORM

Ensure BH included in all aspects of health reform

Support Federal, State, Territorial, and Tribal efforts to develop and implement new provisions under Medicaid and Medicare

Finalize/implement parity provisions in MHPAEA and ACA

Develop changes in SAMHSA Block Grants to support recovery and resilience and ↑accountability

Foster integration of primary and behavioral health care

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People● Stay focused on the goal● Tribal people; culturally appropriate approaches

Partnership● Cannot do it alone● Tribal leaders; AI/NA organizations

Performance● Make a measurable difference● Outcomes defined by AI/AN culture

www.samhsa.gov

SAMHSA PRINCIPLES32